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    Renner1987

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    luis sanchez

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    © All Rights Reserved
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    Mandibular Edentulous Anatomy and Modified Impression Technique RP. Renner, D.DS. Making an accurate impression of the mandibular ‘edentulous dental arch of “the difficult lower jaw.” presents unique problems for the dental practitioner ‘This arch isthe ultimate foundation upon which removable prosthesis is fabricated. Anatomic, phy iologic, surgical, and psychologic considerations of the edentulous patient as well asthe expertise of the denis all playa significant rle in impression making and ultimate patient acceptance of a mandibular com- plete denture When a mandibular prosthesis is not satisfactory the cause can often be traced to faulty impression ‘making procedures. In order to minimize a technical failure on the part ofthe dentist a careful corelation between the anatomic limits ofthe denture foundation and the edentulous custom tay used to make the impression must be made. The purpose ofthis article js twofold: (J) to review both the pertinent static an- stomic landmarks ofthe mandibular denture space and the dynamic nature of muscular influence on the bor- ders of the custom tray $0 that impression making ‘becomes more predictable and; (2) to describe a mod- ified impression aking technique for patients with severely reduced residual ridges. ‘Anatomie considerations Many oral structures change drastically when a patient becomes completely edentulous. The bony foundation (residual ridges) forthe denture, regardless if the pa- tient is treated with prostheses or not, can be cha ‘acterized by a continual reduction of these ridges throughout the patients life.” As a consequence of ‘continual resilal ridge reduction (RRR) the facial muscles (lips and cheeks) become unsupported and have a tendency to collapse into the oral cavity. At the same time the tongue expands its volume to fill the space formerly occupied by the dentition and sup- porting alveolar bone. The oral cavity of the eden- tulous patient therefore develops the so-called typical denture space (Fig. 1). The dynamic nature of the tissues and muscles surrounding this typical denture space determines the form of the polished surface ‘contours ofthe denture. According to Fish the critical factor in denture stability is not its anatomic foun- dation (residual ridges and mucoperisteal covering) but rather muscular function acting on the polished surfaces and teth. ‘The character of the mandibular residual ridge of 1 patient who has been edentulous fora long period ‘of time is one in which te erst ofthe ridge becomes almost at the same level as the surrounding muscu- lature (mentalis and mylohyoid), thus allowing the muscles to easily dislodge the denture. RRR also re- ‘duces the amount of firm mucoperiosteum attached to ‘bone causing usually well defined buccal and lingual vestbules to be eliminated. These major changes in the oral anatomy make it dificult fr the dental prac~ ttione to distinguish the anatomic and functional lim- its ofthe denture space (Fig. 2). (QUINTESSENCE OF DENTAL TECHNOLOGY. MAY/JUNE 1987 qoday jeneds 17 to collapse ofthe buccinator and alteration of the tongue form, According to Brill, Tryde, and Cantor’ denture sta- bility is a result ofthe muscular forces that act and relate tothe different surfaces and borders of the man- ibular denture. “These are (1) te pressure receiving Surface (the occlusal table), (2) the pressure tans- ‘mitting surface (the primary supporting surface or basal seat), and finally, (3) the secondary supporting surface that is comprised ofthe polished surfaces of the denture and the lingual and buccal surfaces ofthe teeth. The junction of the primary supporting surface fd the secondary supporting surfaces is called the “denture borde {erent groups, (1 ble 1). A review ofthese muscle groups and how they will influence the retention and stability of a mandib- ular denture is important for both the dentist during impression making and the dental laboratory techni- cian when making custom trays,’ sting teeth." and ‘creating the denture polished surface contours.” A de- scription ofthe paired stabilizing and dislodging mus- cles will begin at the midline of the mandibular an- terior labial sulcus, proceed posteriorly along. the buccal denture border, ross the retromola pad, ex- tend inferiorly inthe retromlohyoid sulcus and pro- ceed anteriorly on the lingual denture border towards the lingual frenum, Fig. 1 Diagrammatic representation ofa mediolateral rss secon twough he sulin region ofthe st molars. (A) Anatomic Tomtonships in the dentate sate and (@) inthe edentsous sate, Observe tne narrowing ofthe potential space for compete entures ve ) stabilizing and (2) dislodging (Ta- 3) “fhe musculature that envelops and limits the po Ay tential demure space can be classified into two di- QUINTESSENCE OF DENTAL TECHNOLOGY VOLUME 11 NUMBER 3 The labial fremum interrupts the alveotabial sulcus inthe region ofthe mandibular incisors. This usually twiangularshaped (apex pointing superior) fold of mucous membrane covers various types of connective tissue. Consequently this frenum follows the func tional movement of the lower lip, In cases of severe RRR the frenum is transformed into broad bands of tissve located atthe top of the residual ridge and can act as a dislodging force when the lips are moved sideways or pursed, The fibers of the mentalis muscle ran between the frontal surface of the mandible, betwcen the canine fminence and incisive fossa, infenorly, anterior and medially to insert int the skin ofthe chin, Right and Teft muscle fibers fuse in the midline. When there has been severe RRR the mental muscle i lcated a the ‘rest of the residual ridge rather than in the reflection ‘of the alveolabial sulcus. When this muscle contacts to clevate the chin it can markedly decrease both the height and width of the anterior labial vestibule (Figs. 3 and 4), The ies of he ncn briny msc run between the frontal surface ofthe mandible athe canine eminence and run anteriorly and Iaterally 10 the oral commissure where they fuse with fibers of the orbicularis oris muscle. Like the mentalis, espe: =? q [ee ‘The modiolus (Latin for nave of a wheel) “because [ight muscles radiate from i lke the spokes ofa wheel {rom the hub, forms a distinct conical prominence at the comer of the mouth, and in lean muscular young men it can be easly seen whenever they move theit lips or cheeks. defining the crescent fold as the coF- ners of the mouth."* The upper spokes ofthe wheel, the caninus and zygomaticus muscles fx the modiolus firmly to the bony maxilla while the lower spokes, the trangularis muscle fixes it to the inferior border of the mandible (see Fig. 8). When either the buc inator or orbiculais onis muscle is contracted the ‘modiolus must be fixed. “This form of fixation for the ‘modiolus, however, has an enormous advantage, for it may be fixed in any one of a variety of positions either forward or backward, up or down within a con siderable range depending upon the action of the M. cruciatus madioi, so thatthe orbiculars ori can ‘operate from a forward point of origin if we wish 0 say ‘Oh!" or drink soup froma spoon, oritean operate from a backward postion if one should wish to say "Ee" or to play a coronet or bite the lower lip. Which. fion trough the skull In the area ofthe mandibular ‘symphysis. (M) montais musci; (0) oricularis mus- de; (7) tongue: and (G) genioglossus muscle. Con {racture of ether the mentale o genioglossus muscles Severely iis the potential alveolabal or ingualsucus ‘or a mandibular denture 170 QUINTESSENCE OF DENTAL TECHNOLOGY VOLUME 11 ver position the modiolus is fixed in, the orbiculris is tre to carry out the delicate movements of speech for which its intricate internal structure is so beaut fully adapted." fe has a “horseshoe-shaped or crescent-shaped origin, the manillary fibers origi- nate in the mauillay first molar region at the base ofthe alveolar process and run posteriorly and infe riorly distal tothe maxillary tuberosity to inser into the pterygomandibularraphae and then it runs to ter- sninate on the external oblique line of the mandible ‘nthe fst mola region, Almost all bers of the buc- cinator run horizontally from their origin to insert at the modiolus located lateral othe comer ofthe mouth ‘After passing through this knot of facial muscles the superior fibers pass into the upper and the infer fiers nto the lower ip. When the buccinator contracts the cheeks are pressed vigorously against the teeth and alveolar process, The buceinator muscle can be considered an accessory muscle of mastication by po- sitioning the food bolus over the occlusal surfaces of the teth and returning escaped food from the buccal vestibule fo the occlusal table. The action of the m0- Alu isto prevent escape of the food bolus from the comer ofthe mouth as the buecinator moves food up and over the occlusal table ‘The inferior fibers influence the shape ofthe denture border from buccal frena to the pterygomandibular raphae. Inthe edentulous patient much of the attach: ‘ment of the inferior fibers of the buceinator to the extemal oblique line is lox. The denture base in this region can, therefore, be “naximally extended tothe extemal oblique line to cver the primary denture bearing area, the buccal shelf, without these muscle fibers dislodging the denture. Posteiorly the buccal flange can extend tothe masseteric groove while an- ‘erory itis narrowed by the buccal enum and action Fig. 4 The oxgins of tho ments muscle biateraly hhave been outined using a color transfer applicator demonstrating ther position relative to the Gest o he residual nage NuMeer 3 Fig. 6 Diagrammatic representation ofa mediolateral ‘088 section through the skuln region of the crest of the mandibular resioua idge lusrating the anatorsc structures around a manaibular denture, (8) Buccal shell area; (L) retromyiyold area: (7) tongue; (E) esophagus; 1) massetor muscle (2) intemal perygod muscle; (2) stoglossus muscle. (4) palatogiossus (6) superior constrictor ft ‘of the modiolus. The bulk of the buceinator muscle itelf is great stabilizer ofa mandibular denture when it acts against a well contoured and polished buccal surface ‘The masseter muscle defines the postenoe extent of the mandibular buceal denture border. The masseter muscle originates on the zygoma and runs posteriorly, inferiorly, and laterally to insert onthe lateral bordet ofthe mandible. Itformsa sling forthe mandible with its counterpart the intemal pterygoid on the medial surface ofthe mandible. A definite proove (masseter groove) can be seen in the region of the mandibular Second and third molars when the muscle is con- tracted, which causes the denture space to turn acutely medially toward the retromolar pad. Ifa mandibular denture impression is. made with the masseter in a relaxed postion it will dislodge the denture when it contracts by forcefully pushing the buccinator and cheek mucosa anteriorly. The masseter muscle 1s a Aislodging force on a mandibular denture (Figs. 5 and 6) he mandibular denture should extend oad cover the rermmoar pod. It should 90 be overextended Ahly tormplage on the pterygomandiblar raphae Wen tremolo prove secon anor forthe mandibular entre Deause i ona imei tse bundles which are frm and he f= nous atachment of the temporais muscle (Fi. 7). ‘Ie perygomandibular raphae 1s 2 disinet TOK! of tat in fot of and pall othe anterior pla of the mouth and conta the on of oh the bac pate micle ranting ater to form the bulk of the check and pei contro muscle running pos teary ard medal to frm he scala wall ofthe platy. When te mouth vopened widely the raphe (arctched lke a sting and may ft the distal end of the retomolar pad. I the dentre extends ovr this Store i may te dodged sien the mouth 1s Spent wiely ain Yow “The muscles which it the denture space in the posterior lingual area of the mandible, termed the feromsloyoid area of lateral throat frm. ae dis- Iedgingin mare. The shape ofthe mandibular denture inthis aren is very del 10 captre de 10 the Complex muscular actvty bounding the space. The inetalpergod,paatglsus,sploxtoses and sper contrcor mle a the Uiloing mu- cles ce Fi. ema ppg el ges om prerygnd fons of te sll and un infer pose ody, and Inerlyw set on the eet ura: Ofte manuibulr angle fom asliog fr he man- ible with counterpart the master on the lta Sure ofthe mandible As the mandible Is opened tmaximumly the ltrs pterygoid defies and mits te meat prt dial pet of he evr pce. he pln futher imi the poet ‘econ ee nese Tn eects th poglnal ach (saa ely ro eo iin ete aca cof aa Sips Maopingiond ascents firs atta sone ae Se Reece eee meee eiademr Sar ban si ond care. Wes tice ‘oasis etsing Gotten ict stots an pare pera iesclgat cio iCheoiers Pmt eg on he so procs an trary w recreate sa Feng! muscle of the tong. It fancone ihe Siar fashion ss the pales muse mt the dene pce te poser gu reson The infenerprian of espero comic m Glen ataced othe mana is ncn he staeo th poster acl nga sles et contac. When a pn eat tthe slogans ted super conto mans athe tae 172 QUINTESSENCE OF DENTAL TECHNOLOGY VOLUME 11. NUMBER 3 Emp con nae a stunts cy tc Sonepat wach emai nes der aR vacancies itp boo ner ge fro cl a ot py ed Paes pe seed ein tine ape of mat etry ps ie eo dale atp Tees ram tne ee ‘Chere an it pono Te cre mc te te pl ttn bret te in me ri ep gy eT ornt g ps e te re ep ee Sel mide rte mah an ae i pee tiga tis te dh te ce Theis maces feng: gia erica, od ane), an in ce planes ih angst ne aera teat wil ther sustain orale the hp of te og When theresa corition oh ati ofthe cutis nd inti muscles fhe ou one can fave powerless he ings of 4 dent isp imo counteracted equal pres fo th buna (heater ano bili ors) ane a mandibular dene willbe dodge, Tis antagonistic eft of pose CQUNTESSENCE OF Dew’ ‘os mur en cei pores tiae g serene i pcreencase i cn con ma scr sony cage Fe tay snd smerny cae ms epee foci ced Sc eh nn in a Doe pe Clinical procedure |, The det makes a eininary impression ofthe anil detal ach in eter moding com Pound, impression plaster, or inverse bydo- coli wing an open mouth impresion chique TECHNOLOGY NAYIJUNE 1967172 stn ofthe mandibular an in erversibie hyrocollnd | Fig. 8 A proimsnary ing ‘tome tissues mack Fig. 10 Acustom tray is mace on a dental sone cast i ‘upon which the mits tothe denture have been de sented, in atopotymenng aryic rein. Fig. 12. The mandibular custom tray is visual in Spected for stability and lack of over or underexten. ions n hs instance ovoroxtonions have been {ectedin tho rtromyiohyoid areas bilaterally provening {passive seating on the odorous tissues, Fig. 9. The ints the mandibular denture ara penciled Ion the diagnose cast before rat wax i paced, Fig. 11. handle can bo ade wih autopalymerzing acre resin oF a prefrr 9d aluminum hand can be added. Any hand shoud not inertore mth the pa tents ower ip or maxilary residual ge, Fig, 19. The retromolar pad nas been dried and ou lined by means ofa col tansterappictor 174 QUINTESSENCE OF DENTAL TECHNOLOGY VOLUME 11 NUMBER 3 Fig. 14 The massotenc groove, buccal shel area | and extemal obique inw have been marked a smiar fashion win calor ranster appear | (Fig. 8. The aim sgn an impression of he | tal aoe denture ering ae with de Laboratory procedure 1. An autopolymenzing serie resin mandibular ‘custom trays constructed on a dental stone cast made from this preliminary (anatomic) impres ‘on ofthe mandibular dental arch.* Cae is taken to red the anatomic limits of the potential den ture-bearing area including the reromoar pas, buccal shel, residual ridge, buccal labial, and Tingual fren, lingual seus, and retomylohyoid ace (Fig. 3). The custom tay should cover the retromolar pad emily, be several millimeters Short of the labial denture extension and extend to the fll depth inthe lingual sulcus, and be ppropmately relieved allow movement without restriction ofthe various frena (Fig. 10). When the width of the residual ridge is very narow in the anterior region the tray must be reinforced o¢ thickened to ensure tabilty and prevent facture 2. An acrylic resin o preformed aluminum handle Stould be atached tothe top ofthe custom tay land be contoured so that doesnot interfer with movements ofthe lip (Fig. 11) Clinical procedure 4. The dentist should try inthe custom tray ita corally and comect for any over and underexten sions inthe various sulci before modeling com pound is added tothe way. The tay should be Seated with light finger pressure and the dentist Should. proceed around the dental arch ia a Planned order to check the limits ofthe custom tray (Fig. 12), Diret observation and clinical (QUINTESSENCE OF Fig. 15. Extra palpation ofthe custom tay in the fesion ofthe molars an addtional method ascertain bverestensions beyond the extemal oblque line palpation are the methods employed to check a fustom tay for over or underettensions. A con- ‘enient stating place isthe rettomolar pads bi laterally (Fig. 13)-A making tick (color transfer applicator) impregnated wit a gentan violet dye an te used to outline the extent of various an- tome structures and limits to the denture and be easily transfered 0 the ay ach anatomic structure is dried with gauze marked with the color transfer stick ad then the Ary custom tray i inserted and seated with ight fing pressure. It is removed and any overe tensions beyond the anatomic limits are adjusted with acrylic imming burs mounted in slow ‘poe dental handpiece. The retomola pad. mas eters groove, buccal self various fena, labial nd aneio lingual sulcus can be adjusted by this method (Fig. 18) Extension beyond the extemal oblique line can be also determined by external palpation. With the tray seated inraealy the inde finger can be tun from the border ofthe mandible inthe molar region up the facial skin 1 feel the presence of the buceal border ofthe custom tray. When the teay is overextended beyond the external oblique lin the way an be realy palpated ateral fo the body of the mandible (Fig. 13) The retomylohyoid and mylohyoid areas can be adjusted by the use of ether disclosing wax applied tthe borders or via series of small functional adjustments to the tay Uni the cs tom tray is stable to dislodgement when tongue andior swallowing movements are made by the Patient. The patient should not be encouraged to make exaggerated tongue movements when ‘checking the lingual extension ofthe tray. Placing the tongue outside the mouth wil force the dentist to overtion the tay, creating shortened borders ALTECHNOLOGY MAYIJUNE 1967 175 Fig. 17. A static impression of the denture-besring Fig. 16 Modeling plastcis softened overa gas burner asues is made using modeling pastic within the on and placed ito the tse Iting surface ofthe man |

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